Massage Therapy Consultation Intake Form

Please complete the details below and return to Massage by Romero prior to treatment, this form will then be stored in accordance with GDPR Regulations.

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

How did you hear about Massage by Romero?

List any medications, supplements, or herbal remedies you currently take:

Please list allergies or sensitivities:

Please list Injuries or surgeries:

Have you ever received professional Massage?

Preferred Massage Pressure?Light, Medium or Deep?

What are your specific concerns at this time regarding your expectations from the massage?

What is your goal for this session.

By SUBMITTING THIS FORM, you agree to the following:

1) I give my permission to receive massage services.

2) I understand that therapeutic massage is not a substitute for traditional medical treatment or medications.

3) I understand that Massage by Romero does not diagnose illnesses or injuries, or prescribe medications.

4) I have clearance from my physician to receive massage therapy.

5) I understand the risks associated with massage therapy include, but are not limited to:

• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Massage by Romero from all liability concerning these injuries that may occur during the massage session.

6) I understand the importance of informing Massage by Romero of all medical conditions and medications I am taking, and to let Massage by Romero know about any changes to these. I understand that there may be additional risks based on my physical condition.

7) I understand that it is my responsibility to inform Massage by Romero of any discomfort I may feel during the session so he may adjust accordingly.

8) I understand that I or Massage by Romero may terminate the session at any time.

9) I have been given a chance to ask questions about the session and my questions have been answered.

Signature*

Date